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Health Insurance Annual Benefit Limits

Don't leave yourself under-protected...find out exactly how annual benefits work in heath insurance policies.

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In a perfect world, your health fund would provide unlimited cover for all the out-of-hospital health care services you receive. But we don’t live in a perfect world. Every policy will have a limit on the maximum benefit it will pay for various treatments as services. These are known as annual benefit limits and it’s important to be aware of the limits that apply to a policy before taking out cover.

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What is an annual benefit limit?

An annual limit is the maximum amount you can claim for a specific extras service, which resets at the start of a new year. The annual limits on your extras policy will depend on your health fund and the level of cover you have.

However, some funds also impose lifetime limits on certain benefits. Once you have reached this threshold, you will not be able to claim any more rebates for those services.

What are the types of services that have annual limits?

Annual limits usually apply to a wide range of general treatments included in extras cover, such as:

However, there are certain parts of extras cover to which annual limits don’t usually apply, for example ambulance cover.

What is the difference between a combined limit and a sublimit?

When comparing extras cover, it’s important to be aware that sub-limits and combined annual limits may also apply. While your policy may have an annual limit of $1,000 for general dental services, there may also be a sub-limit that sets the maximum amount you can claim for a specific dental treatment, for example a routine checkup or a basic extraction. This sub-limit is subtracted from the larger annual limit.

However, combined annual limits may also apply. For example, your policy may provide up to $300 cover for each of the following services: physiotherapy, chiropractic treatment and osteopathy. However, those services may also be grouped together into one category with a combined annual benefit limit of $750 – so the maximum yearly amount you can claim for all the physio, chiro and osteo services you receive is $750.

How is annual defined?

The definition of annual depends on the calendar your fund uses:

  • Some funds use the calendar year: 1 January to 31 December
  • Some funds use the financial year: 1 July to 30 June

Your benefit tally resets at the end of each year, so check with your health fund to make sure you’re aware of what they deem to be the start of a new year.

When do your benefits reset?

FundWhen Extras ResetFind out more
AHM logoahm health insurance1 JulyMore info
CUA_logoCUA Health1 JanuaryMore info
Picture not describedhealth.com.au1 JanuaryMore info
HCF logoHCF1 JanuaryGo to Site
Medibank logoMedibank Private1 JanuaryGo to Site
NIB logo

NIB

1 JanuaryGo to Site
Qantas Insurance logoQantas Health Insurance1 JanuaryGo to Site
1 JanuaryGo to Site
ACA Health Benefits Fund logoACAAnnual limits do not rollover to the next calendar year. Benefits are paid according to the limit of the year in which the services are provided/purchased.More info
Apia LogoAPIA1 JanuaryMore info
Australian Unity LogoAustralian Unity1 JanuaryMore info
Bupa logoBupa1 JanuaryMore info
CBHS Corporate Health logoCBHS Corporate1 January
CBHS Health Fund logoCBHS Health Fund1 JanuaryMore info
CDH logoCDH Benefits FundNot statedMore info
Defence_Health_Logo_100Defence Health1 JulyMore info
Doctors Health Fund logoDoctors' Health Fund1 JanuaryMore info
Emergency Services Health logoEmergency Services Health1 JanuaryMore info
Frank health insurance logoFrank1 JanuaryMore info
GMHBA health fund logoGMHBA1 JanuaryMore info
GU Health logoGrand United Corporate HealthPolicies reset every 12 months from the effective date that you become a member.More info
HBF logoHBF1 JanuaryMore info
Health Care Insurance logoHealth Care Insurance1 JanuaryMore info
HIF health insurance logo

HIF

1 JanuaryMore info
Health Partners logoHealth Partners1 JanuaryMore info
Latrobe logoLatrobe Health ServicesNot statedMore info
Mildura LogoMildura Health Fund1 JanuaryMore info
MyOwn logoMyOwn Health1 JanuaryMore info
Onemedifund logo

onemedifund

1 JulyMore info
Navy Health Logo

Navy Health

1 JulyMore info
Nurses-and-midwives logoNurses & Midwives Health1 JanuaryMore info
Peoplecare logoPeoplecare Health Insurance1 JulyMore info
Phoenix health fund logoPhoenix Health Fund1 JanuaryMore info
Police health logoPolice Health1 JanuaryMore info
Queensland Country Health Fund logoQueensland Country Health FundMembership year based on when you joinedMore info
RACQ logoRACQ1 JanuaryMore info
RT health fund logoRT Health Fund1 JanuaryMore info
Rbhs logoRBHS1 JanuaryMore info
St.lukes health logoSt.Lukes Health1 JanuaryMore info
Teachers health logoTeachers Health1 JanuaryMore info
Transport health logoTransport Health1 JanuaryMore info
TUH LogoTUH1 JanuaryMore info
UniHealth logoUniHealth1 JanuaryMore info
Westfund logoWestfund1 JanuaryMore info

Do these limits increase?

This depends on your health fund. With some extras cover policies, the annual limits remain the same each year.

However, with other policies, you may be rewarded for your loyalty with a benefit increase each year you remain a member. For example, your annual general dental cover limit in your first year of membership may be $500, but it may rise to $750 in your second year of membership and then continue to increase each year until you’ve reached a set maximum.

These increases typically only apply to some of the more major extras services, such as dental and optical.

Do these limits only apply to extras?

Yes. Hospital cover does not feature a set monetary limit on the benefit amount you are eligible to claim, so annual benefit limits only apply to extras cover. You can find out more about how hospital-only cover works in our handy guide.

What other limits can apply?

There are a few other extras cover limits you should be aware of. The first is a time limit, if you want to receive a rebate from your health fund for a health care service you’ve received, you must lodge your claim within two years of the service date.

The second limit you should be aware of is a service limit, as there may be a limit on the maximum number of times you can claim a benefit for the same service, for example an initial consultation with a physio, in a calendar year.

Finally, many health funds will also limit you to claiming one benefit per fund, per day. So if you receive multiple services within one consultation, you may only be able to claim the service which attracts the higher benefit.

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